34318Christine M Morales's UM reject select

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Form_SCTNID_CTGRY.XX1106FAXCRC_OTHER Progressive PO Box 31260 Tampa, FL 33631 Policy Number: 908322844 Underwritten by: Progressive Select Insurance Co Policyholder: Christine M Morales January 8, 2016 Page of 1 1 Customer Service 24 hours a day, 7 days a week 1-800-776-4737 1-877-280-5587 (fax) Mailing Address: Progressive PO Box 31260 Tampa, FL 33631-3260 Requested policy documents ……………………………………………………………………………………………………………………………………………………….. Uninsured Motorist Coverage Rej/Sel Please sign and return the attached form and include this page for reference. You may fax or mail the information to Progressive. Thank you. Form_SCTNID_CTGRY.FL07048617_SIGNFORM <docindex><index>UMUIMRLN</index></docindex> Policy Number: 908322844 Christine M Morales Page of 1 2 FLORIDA UNINSURED MOTORIST COVERAGE SELECTION/REJECTION FORM YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORIST LIMITS LESS THAN YOUR BODILY INJURY LIABILITY LIMITS WHEN YOU SIGN THIS FORM. PLEASE READ CAREFULLY. Description of coverage Uninsured Motorist coverage provides for payment of certain benefits for damages caused by owners or operators of uninsured motor vehicles because of bodily injury or death resulting therefrom. Such benefits may include payments for certain medical expenses, lost wages, and pain and suffering, subject to limitations and conditions contained in the policy. For the purpose of this coverage, an uninsured motor vehicle may include a motor vehicle as to which the bodily injury limits are less than your damages. Florida law requires that automobile liability policies include Uninsured Motorist coverage limits equal to the Bodily Injury Liability limits in your policy unless you select a lower limit offered by the company or reject Uninsured Motorist coverage entirely. If you are interested in selecting Uninsured Motorist coverage for a limit less than your Bodily Injury Liability limits, or are rejecting this coverage entirely, you must complete and sign the appropriate option below. If you decide to purchase any Uninsured Motorist coverage you can select either "Stacked Uninsured Motorist," or "Non-stacked Uninsured Motorist." The cost of Non-stacked Uninsured Motorist coverage is lower than the cost of Stacked Uninsured Motorist coverage. If you select "Stacked Uninsured Motorist" and you or a family member who resides with you are injured by an uninsured motorist, your policy limits for each motor vehicle listed on the policy may be added together to determine the total amount that may be recovered (stacked) for all covered injuries. Thus, the limits available to you would automatically change during the policy term if you increase or decrease the number of motor vehicles covered under the policy. If you select "Non-stacked Uninsured Motorist" and you or a family member who resides with you are injured by an uninsured motorist, the injured person may not add or combine the coverage provided as to two or more motor vehicles together to determine the limits of uninsured motorist insurance coverage available, except as described in subsection one below. The injured person is limited to the coverage available as to that motor vehicle he/she was occupying if injured in an accident while occupying a vehicle listed on the policy. "Non-stacked Uninsured Motorist" is also subject to the following limitations: 1. If the injured person is occupying a motor vehicle not owned by the injured person or a family member who resides with him/her, the injured person may elect the coverage on the motor vehicle occupied and the highest limits of coverage afforded for any one vehicle insured by the injured person or any family member who resides with him/her. Such coverage shall be excess over Uninsured Motorist coverage on the vehicle the injured person is occupying. 2. If the named insured or family member who resides with him/her is occupying a motor vehicle or motorcycle owned by the named insured or a family member who resides with him/her, there is no coverage if Uninsured Motorist coverage was not purchased on this policy for that motor vehicle or motorcycle. 3. If, at the time of the accident the injured person is not occupying a motor vehicle, he or she is entitled to select any one limit of Uninsured Motorist coverage for any one vehicle afforded by a policy under which he/she is insured. Uninsured Motorist coverage will not apply under this policy if an insured person: (1) elects to recover Uninsured Motorist benefits under another policy when injured as a pedestrian or while not occupying a motor vehicle; or (2) elects to recover excess Uninsured Motorist benefits under a policy other than this policy in addition to the Uninsured Motorist coverage on the motor vehicle he/she is occupying when injured while occupying a motor vehicle that is not owned by any person insured under this policy. Your policy will be issued with "Stacked Uninsured Motorist" unless you select the "Non-stacked Uninsured Motorist" option below. <docindex><index>UMUIMRLN</index></docindex> Policy Number: 908322844 Christine M Morales Page of 2 2 Selection/Rejection of coverage If you do not want "Stacked Uninsured Motorist" coverage equal to your Bodily Injury liability limits, you must select one of the options below. You may select Uninsured Motorist coverage limits up to the Bodily Injury liability limits in your policy or you may reject Uninsured Motorist coverage entirely. If you do not reject Uninsured Motorist coverage entirely you may select "Stacked Uninsured Motorist" or "Non-stacked Uninsured Motorist." ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... Please select one coverage option below and a limit if listed under that option: I want Stacked Uninsured Motorist coverage in the same limits as my Bodily Injury liability coverage. (Note: If you select this option the first paragraph of this form shall not apply.) I want Non-stacked Uninsured Motorist coverage in the same limits as my Bodily Injury liability coverage. I want Stacked Uninsured Motorist coverage at the limit selected below. $10,000/$20,000 $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $100,000 Combined Single Limit $300,000 Combined Single Limit I want Non-stacked Uninsured Motorist coverage at the limit selected below. $10,000/$20,000 $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $100,000 Combined Single Limit $300,000 Combined Single Limit I reject all Uninsured Motorist coverage. I understand and agree that this selection of the option above applies to my liability insurance policy, and will also apply to any renewals or replacements of such policy that are issued with the same Bodily Injury Liability limits as this policy. If I decide to request a change to my selection, the change will not become effective until the Company receives your selection on this form and it has been completed and signed. Signature of named insured Date X ……………………………………………………………………………………………………………………………………………………….. Form 8617 FL (07/04) Uninsured Motorist coverage limits up to the Bodily Injury liability limits in your policy or you may reject Uninsured Motorist coverage entirely. If you do not reject Uninsured Motorist coverage entirely you may select "Stacked Uninsured Motorist" or "Non-stacked Uninsured Motorist." ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... Please select one coverage option below and a limit if listed under that option: I want Stacked Uninsured Motorist coverage in the sa